Healthcare Provider Details

I. General information

NPI: 1992473466
Provider Name (Legal Business Name): THEARY ENG SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 QUEBEC AVE
CORCORAN CA
93212-9715
US

IV. Provider business mailing address

605 CENTENNIAL DR APT B
HANFORD CA
93230-7476
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax:
Mailing address:
  • Phone: 559-992-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number85609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: